D909 Task 1 Ethics Case Study Example

No Insurance, a Failing Liver and a Transplant Program's Financial Clearance Rule: An Ethics Case Study With the Law and the Policy Implications Kept in View

Student Name

Leavitt School of Health, Western Governors University

D909: Healthcare Law and Ethics, Task 1

Course Instructor

Month Day, Year

No Insurance, a Failing Liver and a Transplant Program's Financial Clearance Rule: An Ethics Case Study With the Law and the Policy Implications Kept in View

The Case

Daniel Reyes is a composite 52-year-old self-employed electrician with cirrhosis caused by metabolic dysfunction-associated steatohepatitis. He lost his marketplace health insurance last year after missing premium payments during a slow season. He was admitted through the emergency department of Lakeside University Hospital, a composite nonprofit academic hospital, with bleeding from esophageal varices. The team stopped the bleeding and stabilized him. His hepatologist believes that without a liver transplant he is unlikely to survive more than a year or two, and she has referred him to the hospital's transplant program for evaluation.

The transplant program's policy requires financial clearance before a patient begins the formal evaluation, meaning proof of insurance or another payment source for the transplant and for lifelong immunosuppressive medications. Mr. Reyes has neither. The transplant administrator has asked the hospital's ethics consultation service and the vice president of patient financial services whether the program should begin his evaluation.

The Ethical Issues

The central question is whether a hospital may, or should, withhold the first step toward a potentially lifesaving treatment because the patient cannot pay for it. Beneath it lie two further questions: whether it is responsible to transplant a scarce organ into a patient who may not be able to afford the medications needed to keep it, and whether a financial rule that falls hardest on uninsured and publicly insured patients is consistent with the hospital's charitable mission.

Ethical Principles in Tension

The analysis uses the four principles described by Beauchamp and Childress (2019). Beneficence favors evaluation: transplant is Mr. Reyes's best chance of survival, and evaluation is how the team learns whether he is a candidate at all. Justice points the same way. Access to transplant should depend on medical need and likely benefit, not on ability to pay, and the evidence shows that financial barriers do not fall evenly. In a study of 495 patients with liver cancer referred for transplant at one center, public insurance was independently associated with lower odds of being placed on the waitlist, and social determinants of health were important barriers to completing the transplant pathway (Baker et al., 2026).

Nonmaleficence pulls in a more complicated direction. A transplant recipient who cannot obtain immunosuppressive drugs is at high risk of rejecting the new organ. Transplanting a liver without a plan to pay for those drugs could harm Mr. Reyes and waste an organ that another patient might have used. Stewardship, the responsible use of limited resources, reinforces that concern: donated livers are scarce, and the hospital's charity care budget is finite.

Respect for autonomy also matters. Mr. Reyes wants to be evaluated and has said he will do whatever is required. A decision made about him without his involvement in solving the financial problem would disregard his own capacity to act.

The Law and What It Requires

The Emergency Medical Treatment and Labor Act (EMTALA) required the hospital to screen Mr. Reyes when he arrived with bleeding and to stabilize him regardless of his ability to pay, which it did. EMTALA does not require a hospital to provide elective or planned services after stabilization, so it does not by itself require the hospital to begin a transplant evaluation.

Because Lakeside is a charitable hospital, federal tax law adds obligations. Under the federal tax rules in Section 501(r), a charitable hospital must have a written policy on financial assistance that covers emergency and other medically necessary care, states the eligibility criteria and how to apply, and is widely publicized (Internal Revenue Service, n.d.). If Lakeside's policy treats transplant evaluation as medically necessary care, Mr. Reyes may qualify for assistance with the evaluation itself. The policy does not, however, reach his future outpatient medications, and it does not create a right to a transplant.

Federal civil rights law bars health programs from discriminating by race, color, national origin, sex, age or disability. Insurance status is not itself a protected category, but a financial rule that produces unequal outcomes by race or disability could raise concerns and should be monitored. In short, the law permits a financial clearance requirement but does not require it, and it gives the hospital room to decide how that requirement should work.

Implications for Hospital Policy

The case exposes a gap between two policies. The transplant program's financial clearance rule treats payment as a gate before any evaluation, while the hospital's financial assistance policy exists to keep medically necessary care from depending on ability to pay. Applied as written, the clearance rule means that the patients least able to pay never learn whether they are candidates, and the hospital never learns how many such patients it turns away. That is difficult to reconcile with a charitable mission and with the equity evidence above.

Recommended Course of Action

For Mr. Reyes, I recommend that the program begin the medical evaluation now under the financial assistance policy, while a transplant financial counselor works in parallel to secure coverage. Possible paths include a Medicaid application if his illness qualifies him on the basis of disability, marketplace coverage at the next enrollment period and pharmaceutical assistance programs for immunosuppressive drugs. Listing him for transplant should wait until a realistic plan exists to pay for the transplant and his medications, because transplanting without that plan would risk the harm the nonmaleficence principle warns against. Mr. Reyes should be told plainly what the evaluation can and cannot promise and be involved in every step of the financial plan.

For future cases, the hospital should revise its transplant financial clearance policy in four ways. Medical and financial evaluation should run in parallel rather than in sequence. Any decision to stop an evaluation for financial reasons should be reviewed by the ethics committee. The financial assistance policy should state clearly whether transplant evaluation is covered. And the program should track every patient whose evaluation is delayed or stopped for financial reasons, by insurance type, race and ethnicity, and report the results to the board's quality committee each year.

Conclusion

The law permits Lakeside to require financial clearance before a transplant evaluation, but permission is not the same as justification. Weighing beneficence and justice against nonmaleficence and stewardship leads to a middle course: begin the evaluation, work actively on coverage and list only when the medications that protect the organ can be paid for. The case also shows that an administrative rule can quietly decide who receives care, and that hospital leaders should examine such rules as carefully as any clinical decision.

References

Baker, B., Aridi, T. G., Patel, M., Carter, A., Singleton, C., Ross-Driscoll, K., Orman, E., Desai, A. P., Ghabril, M., Chalasani, N., Kubal, S., Holden, J., & Nephew, L. D. (2026). Social determinants are important barriers to completion of the liver transplant pathway and are associated with waitlisting and mortality in hepatocellular carcinoma. Digestive Diseases and Sciences, 71(1), 138-154. https://doi.org/10.1007/s10620-025-09278-3

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Internal Revenue Service. (n.d.). Financial assistance policies (FAPs). Retrieved September 29, 2026, from https://www.irs.gov/charities-non-profits/financial-assistance-policies-faps